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And we must remember: Any form of abuse that comes from the very people who are supposed to protect us, to whom we have no choice but to make ourselves vulnerable, is the most destructive of self.
Gloria Steinem, Revolution from Within, '1992
As I researched this topic, I came upon a book, Behind Closed Doors: Gender, Sexuality And Touch In The Doctor/Patient Relationship,1 by Angelica Redleaf, a Rhode Island chiropractic physician. Redleaf so thoroughly and succinctly explained the subject at hand that I decided to obtain permission from the publisher to reprint excerpts of her book. There is, after all, no need to reinvent the wheel. Some adaptations have been made to apply her information to massage therapists and other bodywork practitioners, but the theme and perceived intent of her work is unchanged.
The information offered in this segment of Redleafs writing entitled What Is Misconduct,
is important to all bodyworkers, whether you consider yourself to be a part of the service industry, health profession or spa industry. It applies to the employer, the employed, the practitioner, the consumer, co-workers, the teacher and the student.
The number of sexual misconduct complaints against health-care professionals is increasing at an alarming rate. Allegations of sexual misconduct are creating casualties on all sides: health-care professionals who lose their licenses, practices or reputations; patients and clients who are traumatized by inappropriate or abusive behavior, or behavior that they perceive as abusive; and health-care professions that are publicly humiliated or singled out for unflattering media attention.
A Fiduciary Failure
Sexual misconduct, is, to say the least, a very complex problem. It encompasses issues of sex, gender, power and communication, as well as, in some cases, a real pathology on the part of the health-care professional.
Sexual misconduct occurs when the fiduciary aspect of the health-care relationship is compromised.
Fiduciary is a legal term that is applied to a professional in whom a client places his or her trust. Because such professionals are in positions of power relative to their clients, the law holds them to a higher standard of behavior. They are required to place the interests of their clients above and before their own. A comprehensive, even exhaustive, exploration of this and related topics is presented in the book, Sexual Abuse By Professionals: A Legal Guide.2
All health-care professionals have a fiduciary relationship with their clients. In other words, the professional is in a position of power, while the client is in a position of weakness and vulnerability. Although the client may not be directly aware of the power imbalance, the professional is nonetheless obligated to understand and control its limits.
An Ancient Transgression
The problem of misconduct has been with us for centuries. It was addressed by the Greek physician Hippocrates in the fourth or fifth century B.C., in the Hippocratic oath that some members of the medical profession continue to use today:
Whatever house I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief, and in particular, of sexual relationships with both female and male persons.3
Similar admonishments to doctors, warning them against inappropriate sexual behavior toward their patients, have been found in European medical texts from the Middle Ages and Renaissance.
An Equal Opportunity Problem
Statistics on the subject reveal that 70 percent of sexual misconduct complaints against health professionals are filed by female patients or clients against male professionals. Approximately 20 percent are from female patients or clients complaining about female professionals. Of the remaining 10 percent of complaints, roughly 5 percent are from male patients or clients bringing allegations against women. Females, therefore, make up about 90 percent of the victims of sexual misconduct, and 25 percent of the alleged perpetrators.4 It should be noted, however, that many of those working in the field
have speculated that male victims of professionals of either gender are underrepresented across the board because of particular male characteristics inhibiting both recognition and reporting [of abuse].5
Females may think they are immune to complaints of misconduct, but the statistics prove them wrong. What is more, women may be especially at risk from the very obsessive patient or client. For physicians, the behavior that tends to be the most obsessive is that which occurs between and female patient and a female doctor.6
Breaking The Silence
Recipients of health care used to keep silent about improper behavior, but that is rapidly changing. Now, they are speaking out in record numbers
and this is only the beginning.
Until very recently, the complaint process has been little-known, little-used and far from impartial. To quote the organizers of the Third International Conference on Sexual Exploitation by Health Professionals, Psychotherapists and Clergy,
The tendency is to shoot the messenger, blame the victim and coddle the man.7 However, as patients and clients become less afraid of complaining, as awareness of the complaining process rises, and as the complaint process itself becomes fairer and less humiliating for the person filing charges, the number of complaints can be expected to continue its dramatic increase.
As things now stand, it is up to clients and patients to monitor the behavior and regulation of the practitioners. And it is through their complaints that this monitoring takes place. Women, especially, have become increasingly sensitive to inappropriate or
old-style behavior on the part of either male or female practitioners. In the treatment setting, as in greater society, they have taken the lead in the fight against abuse, misconduct and harassment.
The unequal relationship between health-care practitioner and patient or client has taken a tremendous toll, and those persons with the least power in our society
primarily women, children and members of ethnic and racial minorities have been its principal victims. The professionals whose power is now being eroded by increasing scrutiny and regulation may not like the message, but shooting the messenger is hardly the answer.
Widespread educational changes are necessary to prevent a substantial percentage of the next generation of health practitioners from compromising their patients and clients welfare and the public trust. In some places, that training already has begun. As for the current health professionals whose education included no training in gender, sexuality, communication and other important skills
it is never too late to learn.
What is more, in an increasingly consumerist health-care market, embracing the skills of the new practitioner can bring benefits not only of prevention but also of profit. Those practitioners who develop a strong sense of awareness of their own attitudes and behavior; cultivate a wide range of skills in interpersonal communication; and adopt office procedures with their patients and clients, especially their female patients and clients, will be far more likely to become or remain successful
as well as to prevent unnecessary difficulties for themselves and their patients and clients.
Sexual Misconduct vs. Sexual Harassment
What are the differences? Both sexual misconduct and sexual harassment can create significant problems in a health-care practice. The two issues are not identical, but they are closely related: Each can be thought of as a boundary violation, occurring when one person
s safe space is invaded by another.
Sexual Misconduct. This involves the behavior of a doctor or other health-care professional toward a patient or client. An understanding of this issue is vital to all health-care professionals.
The boundary violations that constitute sexual misconduct do not necessarily involve sexual intercourse between the practitioner and the client. Inappropriate talk or touching, or unnecessary examinations or treatments, also can qualify.
The laws and professional regulations regarding sexual misconduct are still in a state of flux. But for a hint as to where they are likely to go, it is possible to examine the more fully evolved body of law and regulations in this area.
Sexual Harassment. This generally involves the behavior of a supervisor, manager, employer or employee toward staff at the same or a lower level of power. An understanding of this issue is vital to all health-care practitioners, with the possible exception of those in solo practice who have no staff.
Sexual Harassment is an issue arising in a work place or an educational institution. It generally involves one person having power over anothers employment, money, grades or advancement, and abusing that power, though sometimes it instead involves harassment by a co-worker. There are two recognized forms of sexual harassment:
1) Quid pro quo a demand for sexual favors in exchange for job benefits;
2) Hostile work environment unwelcome acts such as physical or verbal conduct, or visual displays, that make the individuals job difficult.
The U.S. Equal Employment Opportunity Commission (EEOC) defines sexual harassment as
unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature when:
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Submission to such conduct is made a term or condition of an individuals employment, either implicitly or explicitly;
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Submission to, or rejection of, such conduct is used as a basis for employment decisions affecting such individual;
-Such conduct has the purpose or effect of unreasonably interfering with an individuals work performance or creating an intimidating, offensive, or hostile work environment.
Harassment can come in the form of physical abuse, such as touching, hugging and stroking. It can come in the form of verbal abuse, which may include inappropriate ways of addressing a person, use of sexually explicit language, or use of words that refer to an individuals body parts, such as displaying
girlie or hunk calendars or other visually offensive material, regardless of whether that material is intended to offend. The intent of actions such as these generally is difficult to determine. But a determination of intent is not necessary to finding of sexual harassment. In cases where it can be established that there was an intent to offend, heavier penalties may be exacted.
A finding of quid pro quo sexual harassment requires that a plaintiff prove that receiving job benefits or protection from job detriments was dependent upon his or her submission to a supervisors unwelcome sexual demands.
Claims of a hostile work environment generally require that a plaintiff prove not only one offensive incident, but a pattern of offensive behavior
unless the one incident was especially outrageous. A single use of offensive language, or a single hug or bump in the hallway, is not sufficient. A hostile work environment claim must prove two things: 1) subjectively, the individual had to regard the behavior as sexual harassment; and 2) another reasonable person would also regard this incident or behavior as sexual harassment.8
[The reasonable person measure has been modified somewhat in recent years in recognition of the fact that some material, speech, or behavior that is considered outrageous by most women is regarded as acceptable by many men. Instead of a
reasonable person, therefore, a reasonable woman standard has been used by the courts in some male/female harassment cases.]
An institutions liability can be established where the employer is found to have had direct or constructive notice of any of these types of sexual harassment, and failed to take immediate and appropriate action. Some of the factors that have been considered by courts and enforcement agencies in determining liability are the nature of the conduct, the frequency and openness of the conduct, and whether it could easily have been avoided by the victim.
One longstanding question about sexual harassment recently has been answered: In a March 4, 1998, decision, the U.S. Supreme Court unanimously ruled
that federal law protects employees from being sexually harassed in the workplace by the same sex.
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What Are The Similarities?
Abuse of Power. Sexual misconduct and sexual harassment are similar in that each generally involves a person of greater power taking advantage of a person of lesser power.
Sexual harassment is particularly volatile because it often fuses two levels of power: the power of employers over employees and the power of men over women.... It is the confusion of public and private, bringing together two arenas of mens power over women. Not only are men in positions of power in the workplace, but we are socialized to be the sexual initiators and to see sexual prowess as a confirmation of masculinity, writes Michael Kimmel of SUNY Stonybrook, a sociologist, a prolific author and leader in mens studies.10 His words about male/female sexual harassment apply just as well to male/female sexual misconduct.
Such abuses of power used to go unnoticed, for the most part, except by their victims. They were born in silent shame, or were even considered acceptable. In the last few decades, however, that has begun to change. More and more, those who have been abused or wrongfully treated are coming forward.
Possible Absence of Intent. Sexual misconduct and harassment also are similar in that each often arises out of a lack of awareness of what kinds of behavior are offensive or even harmful. As a result, preventive measures for sexual misconduct and sexual harassment also are quite similar: We all need to learn ways of prevention that will safeguard those people with whom we work and those with whom we are involved in health-care relationships.
Prevention Strategies
The strategies for preventing either sexual harassment or sexual misconduct include getting training to facilitate an understanding of the power of roles; gaining an understanding of the impact of ones own sexuality and the sexuality of those with whom one interacts professionally; learning appropriate ways of behaving around and of communicating with people of the same gender and of opposite genders; learning what behaviors are considered unacceptable; learning about situations that may lead up to such transgressions; learning about the effects of abuse and harassment; and understanding the potential legal and financial consequences of unacceptable behavior.
Here are five specific steps that health-care professionals can take to help prevent sexual harassment by supervisors or co-workers:11
1) Develop and post a policy against harassment;
2) Teach employees what constitutes harassment;
3) Improve morale and productivity;
4) Address complaints before they develop into litigation;
5) Establish an effective and confidential complaint process.
The five specific steps below can be used by health-
care professionals to help prevent sexual misconduct by caregivers:12
1) Develop and post a Patients or Clients Bill of Rights;
2) Teach yourself and your staff what behavior is unacceptable;
3) Improve rapport and communication with clients or patients;
4) Address client or patient complaints and dissatisfaction promptly, before they develop into litigation;
5) [a.] Establish an effective and confidential complaint process; this is an option primarily for hospitals, for other large health-care organizations, and for state or national professional associations and the organizations that regulate them;
[b.] Or, for individuals and small-group practices, establish checks and balances on your own behavior and attitudes; for bodywork professionals, this could include obtaining feedback on your techniques.
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Behind Closed Doors, by Angelica Redleaf. ©1998 by Angelica Redleaf. Reproduced with permission of Greenwood Publishing Group, Inc., Westport, Connecticut.
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Dianne Polseno, former chair of the National Ethics subcommittee, is a practicing massage therapist, practical nurse, author and publisher of Comprehensive Review Manual For Massage Therapists. A teacher at Bancroft School of Massage Therapy, she receives mail at dipol@aol.com or 1 Raymond St., North Smithfield, RI 20896-8215.
References
1. Redleaf, Angelica, Behind Closed Doors: Gender, Sexuality, and Touch in the Doctor/Patient Relationship.
2. Bisbing, Steven B., Linda Mabus Jorgenson, and Pamela K. Sutherland, Sexual Abuse by Professionals: A Legal Guide (Charlottesville, VA: Michie, 1995).
3. From The Hippocratic Oath, a translation by Ludwig Edelstein that is No. 1 of the Supplements to the Bulletins of the History of Medicine (Baltimore: Johns Hopkins University Press, 1943).
4. Comments made by Gary R. Schoener, in Assessment, Treatment, and Supervision of the Professional Offender, a seminar presented by Schoener and John Gonsiorek, at
Is Never O.K., The Third Conference on Sexual Exploitation by Health Professionals, Psychotherapists, and Clergy, in Toronto, Canada, Oct. 13, 1994.
5. Gonsiorek, John C., Perpetrators, in Breach of Trust: Sexual Exploitation by Health Care Professionals and Clergy, John C. Gonsiorek, ed. (Thousand Oaks, CA.; Sage Publications, Inc., 1995), 131.
6. Private telephone conversation with Gary R. Schoener, November 1994. An internationally acclaimed consultant on issues of professional ethics and boundaries, Schoener is a licensed clinical psychologist; a member of the faculty at the School of Public Health, University of Minnesota; a co-author of Psychotherapists Sexual Involvement With Clients and Assisting Impaired Psychologists; executive director of the Walk-In Counseling Center in Minneapolis, Minn.; and a member or the American Psychological Associations Task Force on Sexual Impropriety.
7. From the schedule of conference events published by organizers of Its Never O.K., The Third International Conference on Sexual Exploitation by Health Professionals, Psychotherapists and Clergy, held in Toronto, Ontario, Canada, Oct. 13-15, 1994.
8. This description of sexual harassment is based to a great extent upon material presented in
Sexual Harassment in the Workplace: Corporate Strategies for Protection and Defense, a seminar handout (Providence, RI: Litch & Semenoff, Attorneys at Law, May 2, 1995).
9. Greenhouse, Linda, of The New York Times, Same-Sex Harassment Ruled Illegal, as the article appeared in The Providence Journal-Bulletin, Tuesday, March 5, 1998, A-1, 11.
10. Kimmel, Michael S., Clarence, William, Iron Mike, Tailhook, Senator Packwood, Spur Posse, Magic É And Us, in Transforming a Rape Culture, Pamela R. Fletcher and Martha Roth, eds. (Minneapolis: Milkweed Editions, 1995). 130 -131.
11. These five steps for preventing sexual harassment are based on the list of preventive measures presented in the handout
Sexual Harassment in the Workplace: Corporate Strategies for Protection and Defense.
12. Ibid.
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